July 13, 2017

Following reports that an unknown illness had been identified in a remote community 1400 kilometres from the state capital, a multidisciplinary team of health workers and administrative officers was dispatched. They immediately swung into action conducting field investigations. They traced and collected blood samples from the suspected cases and sent the samples back to the capital for testing. The tests came back positive.

The response team used an alert system to notify members of the community of the cases. It also collected samples and tested them using a mobile laboratory.

The team also succeeded in ensuring that health workers were not infected. In previous outbreaks in West Africa this had been a problem. Many health workers who came to help contracted the disease and transmitted it to patients and community members.

Tracing the source

Studies show that bats are the reservoir of the Ebola virus. Wild animals get infected when they come in contact with infected faeces or body fluids from the bats.

The virus is transmitted to people when they come in direct contact with fluids or when they eat meat from infected bush meat. An infected person then spreads the disease to other people. An outbreak ends when the human to human transmission is interrupted.

The incubation period of the virus ranges from 2 to 21 days which means that an infected person can take up to 21 days to develop symptoms.

An outbreak of Ebola is declared over when 42 days have passed since the last confirmed case tests negative for the virus. So, the count of the 42 days starts when the last confirmed case is declared free of the virus.

During these 42 days an elaborate surveillance system is put in place. This includes an alert system that can be activated if a new suspect is identified, as well as testing capability. The surveillance system remains in place for several weeks after the last confirmed case has been declared negative. This is to make that any cases can be identified. An eye is also kept open for possible infections from the wild.

Lessons learnt

The DRC experience underscores the fact that there are a number of areas that need special attention in an Ebola outbreak.

First, governments should have efficient nationwide surveillance systems to monitor priority health conditions, beginning at the community level. This early warning system can detect deviations from the norm, including suspected Ebola cases.

The surveillance systems should be linked to laboratory diagnostics for rapid confirmation of cases. This is especially possible today with the advent of field ready technologies reducing the turnaround time for diagnosis.

Secondly, an outbreak response team with regional operation centres should be established and tested before an outbreak begin. It requires coordination among the different stakeholders to enable a rapid response. They should also be in touch with international agencies in case of cross-border emergencies.

Thirdly, public health education plays a pivotal role because the quick spread of the disease is often fuelled by community practice like burial rites and acceptance of disease survivors. This means that appropriate communication on the risks of the disease, infection, treatment and management should be delivered to the public in a culturally appropriate way.

And finally, a resourceful public health system is necessary for a timely response. Governments should improve primary health care facilities by hiring and training more health workers and having efficient infrastructure, logistics, health information, governance and drug supply systems.

In all, we need to remain vigilant because we’re dealing with “when” rather than “if” the next large outbreak happens.

Introduction: During the flare-ups of Ebola virus disease (EVD) in Liberia, Sinoe County reactivated the multi-sectorial EVD control strategy in order to be ready to respond to the eventual reintroduction of cases. This paper describes the impacts of the interventions implemented in Sinoe County during the last flare-up in Monrovia, from April 1 to June 9, 2016, using the resources provided during the original outbreak that ended one year back.

Methods: We conducted a descriptive study to describe the key interventions implemented in Sinoe County, the capacity available, the implications for the reactivation of the multi-sectoral EVD control strategy, and the results of the same. We also conducted a cross-sectional study to analyze the impact of the interventions on the surveillance and on infection prevention and control (IPC).

Results: The attrition of the staff trained during the original outbreak was low, and most of the supplies, equipment, and infrastructure from the original outbreak remained available. With an additional US$1755, improvements were observed in the IPC indicators of triage, which increased from a mean of 60% during the first assessment to 77% (P=0.002). Additionally, personal/staff training improved from 78% to 89% (P=0.04). The percentage of EVD death alerts per expected deaths investigated increased from 26% to 63% (P<0.0001).

Discussion: The small attrition of the trained staff and the availability of most of the supplies, equipment, and infrastructure made the reactivation of the multi-sectoral EVD control strategy fast and affordable. The improvement of the EVD surveillance was possibly affected by the community engagement activities, awareness and mentoring of the health workers, and improved availability of clinicians in the facilities during the flare-up. The community engagement may contribute to the report of community-based events, specifically community deaths. The mentoring of the staff during the supportive supervisions also contributed to improve the IPC indicators.

Now comes the World Bank with a novel program that could help realize the goal of rapid response to such emergency health threats and save lives. The bank has announced the issuance of $500 million in specialized bonds and derivatives that will help poor countries cope with a pandemic such as Ebola.

The effort will create a trust fund, the Pandemic Emergency Financing Facility, that can be quickly deployed for pandemic response, complementing the WHO fund. Investors who buy the bonds and provide the trust-fund financing upfront will reap premiums (at first, Japan and Germany are covering the premiums) but will also be taking a risk. If there is a major outbreak, the investors will lose some or all of their cash.

This is the first time such an approach has been tried for pandemic risk, but a similar idea underlies insurance against other natural disasters and catastrophes. One big advantage is that instead of waiting around for slow-moving national governments to fund a disease response, the resources necessary for saving lives will be available quickly, when they can do the most good.

The trust-fund money will be used to respond to six viruses that are most likely to cause a pandemic, including influenza, Ebola, severe acute respiratory syndrome and Middle East respiratory syndrome. The financing to 77 eligible countries will be triggered depending on how far and fast a disease spreads and whether it crosses international borders.

When putting the program together, World Bank officials back-tested it against the history of the Ebola pandemic in 2014. They think, had it been in place, money would have flowed three months sooner than it did. Of course, money isn’t everything — political decisions, biomedical research, proper alerts and communication are also critical factors in a rapid response. But having a robust fund to send in the first teams is a promising and innovative step forward by the World Bank, and a worthy legacy of the Ebola catastrophe.

The ECDC Communicable Disease Threats Report (CDTR) is a weekly bulletin for epidemiologists and health professionals on active public health threats. This issue covers the period 2 July - 8 July 2017 and includes updates on measles, Ebola virus disease, influenza A(H7N9), Legionnaires' disease, poliomyelitis and West Nile fever.

Brazzaville/Kinshasa, 2 July 2017 – Today, the World Health Organization (WHO) declared the end of the most recent outbreak of Ebola virus disease (EVD) in the Democratic Republic of Congo (DRC).

The announcement comes 42 days (two 21-day incubation cycles of the virus) after the last confirmed Ebola patient in the affected Bas-Uélé province tested negative for the disease for the second time. Enhanced surveillance in the country will continue, as well as strengthening of preparedness and readiness for Ebola outbreaks.

"With the end of this epidemic, DRC has once again proved to the world that we can control the very deadly Ebola virus if we respond early in a coordinated and efficient way,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General.

Related to the outbreak, 4 people died, and 4 people survived the disease. Five of these cases were laboratory confirmed. A total of 583 contacts were registered and closely monitored, but no known contacts developed signs or symptoms of EVD.

On 11 May 2017, WHO was notified by the Ministry of Public Health of the virus among a cluster of undiagnosed illnesses and deaths with haemorrhagic signs in Likati Health Zone. Likati is a remote, hard to reach area, which shares borders with the Central African Republic and two other provinces of DRC. Cases of the disease were reported in four health districts. This is DRC’s eighth outbreak of EVD since the discovery of the virus in the country in 1976.

The effective response to this latest EVD outbreak in Africa was achieved through the timely alert by local authorities of suspect cases, immediate testing of blood samples due to strengthened national laboratory capacity, the early announcement of the outbreak by the government, rapid response activities by local and national health authorities with the robust support of international partners, and speedy access to flexible funding.

Coordination support on the ground by the WHO Health Emergencies Programme was critical and an Incident Management System was set up within 24 hours of the outbreak being announced. WHO deployed more than 50 experts to work closely with government and partners.

July 01, 2017

Democratic Republic of Congo declared its two-month Ebola outbreak officially over on Saturday after 42 days without recording a new case of the disease.

The outbreak in Congo's remote northeastern forests, a record eighth for the country where the disease was first discovered in 1976, killed four out of the eight people infected, Health Minister Oly Ilunga said in a statement.

"I declare on this day, at midnight, the end of the outbreak of the hemorrhagic fever of the Ebola virus in DRC," Ilunga said.

Congolese health authorities approved the use of a new experimental vaccine but ultimately declined to deploy it due to the small scale of the outbreak and logistical challenges.

The latest outbreak came a year after the end of the virus' deadliest episode in West Africa, which killed more than 11,300 people and infected some 28,600 as it swept through Guinea, Sierra Leone and Liberia and caused alarm around the world.

After the largest Ebola virus outbreak in history, experts have attempted to answer how the Zaire ebolavirus species emerged in West Africa and caused chains of human-to-human transmission. The widespread and untimely infection of Health Care Workers (HCW) in the affected countries accelerated spread of the virus within the community. Among the reasons attributed to this trend, it must be considered that HCW were exposed to the virus in their occupational environment.

The contribution of environmental conditions to the spread of Ebola in West Africa was examined by investigating the effect of temperature/humidity on the virus’s environmental persistence and by modeling if saturation (liquid stress) allows for penetration of Ebola virus through personal protective equipment (PPE). Ebola-Makona virus persisted on PPE and materials found in outbreak settings for less than 72 hours at 27 °C and 80% relative humidity (RH). A difference in virus penetration was observed between dry (5%, 1/21 tests) and saturated (33%, 7/21 tests) samples of PPE. Infectious virus particles penetrated through saturated coupons of Tyvek Micro Clean, Tychem QC, whole surgical masks and N95 respirators.

These findings suggest inclusion of saturation or similar liquid stress simulation in protective equipment testing standards.

Safely burying Ebola infected individuals is acknowledged to be important for controlling Ebola epidemics and was a major component of the 2013–2016 West Africa Ebola response. Yet, in order to understand the impact of safe burial programs it is necessary to elucidate the role of unsafe burials in sustaining chains of Ebola transmission and how the risk posed by activities surrounding unsafe burials, including care provided at home prior to death, vary with human behavior and geography.

Methodology/Principal findings

Interviews with next of kin and community members were carried out for unsafe burials in Sierra Leone, Liberia and Guinea, in six districts where the Red Cross was responsible for safe and dignified burials (SDB). Districts were randomly selected from a district-specific sampling frame comprised of villages and neighborhoods that had experienced cases of Ebola. An average of 2.58 secondary cases were potentially generated per unsafe burial and varied by district (range: 0–20). Contact before and after death was reported for 142 (46%) contacts. Caregivers of a primary case were 2.63 to 5.92 times more likely to become EVD infected compared to those with post-mortem contact only.

Using these estimates, the Red Cross SDB program potentially averted between 1,411 and 10,452 secondary EVD cases, reducing the epidemic by 4.9% to 36.5%.

Conclusions/Significance

SDB is a fundamental control measure that limits community transmission of Ebola; however, for those individuals having contact before and after death, it was impossible to ascertain the exposure that caused their infection. The number of infections prevented through SDB is significant, yet greater impact would be achieved by early hospitalization of the primary case during acute illness.

June 17, 2017

On 15 June 2017, no new confirmed or probable cases were reported. Since the last situation update on 13 June, 9 alerts have been reported and investigated of which two fulfilled the case definition as a suspected case. Both of these suspected cases were from Ngayi. Samples were collected and both tested negative by PCR for EVD. Therefore there are currently a total of five confirmed and three probable cases.

The last confirmed case was isolated on 17 May 2017 and tested negative for EVD by PCR for the second time on 21 May 2017. Of the confirmed and probable cases, four survived and four died, resulting in a case fatality rate of 50%. The confirmed and probable cases were reported from Nambwa (four confirmed and two probable), Ngayi (one probable) and Mabongo (one confirmed).

Data modelling suggests that the risk of further cases is currently low but not negligible, and decreases with each day without new confirmed/probable cases. As of the reporting date, 95% of simulated scenarios predict no further cases in the next 30 days.

June 15, 2017

As a battle-scarred veteran of online education going back to the 1990s, I'm delighted to see the arrival of OpenWHO:

OpenWHO is WHO’s new interactive, web-based, knowledge-transfer platform offering online courses to improve the response to health emergencies. OpenWHO enables the Organization and its key partners to transfer life-saving knowledge to large numbers of frontline responders.

These are free, self-paced courses on topics like MERS and pandemic and epidemic-prone diseases. Future courses will deal with Ebola, pandemic influenza, and occupational health and safety. I think I'm going to sign up for Communication Essentials for Member States.